Comprehensive Neurological Examination
Joanne V. Hickey
PURPOSES
The purposes for conducting a neurological physical examination by the physician are (1) to determine whether nervous system dysfunction is present, (2) to diagnose disease of the nervous system, and (3) to localize disease within the nervous system. Although diagnosis of disease is usually the responsibility of the physician, advanced practice nurses also may conduct the neurological examination. It is the purpose of the data collection that differentiates medical practice from nursing practice. The nursing purposes are (1) to determine whether nervous system dysfunction is present, (2) to identify functional deficits and how they impact on the individual’s ability to function in activities of daily living and other aspects of life, and (3) to determine the human responses to actual or potential health problems precipitated by the dysfunction. The data collected create a database for planning care that is patient centered.
The author wishes to acknowledge the helpful review and suggestions of Bahia Elkamand, RN, BSN in the revisions or this chapter.
Advanced practice nurses may overlap with physicians in the purposes of the examination based on legal authority to practice in advanced practice roles.
The neurological physical examination is included in this text for several reasons. First, the neurological physical examination provides a comprehensive database of critical information about the patient’s neurological function. As part of the patient’s record, it is available to nurses and other health care providers to review. Second, a review of these data by nurses may be helpful in identifying areas of special consideration in neurological assessment, as well as specific observations to be made and documented. These points should be noted in the patient’s individualized care plan. Third, potential multidisciplinary collaborative problems may be suggested by the dysfunction identified. For example, a patient with ataxia, a symptom of cerebellar dysfunction, will usually have problems with balance and coordination and needs supervision when ambulating to prevent falls. The potential for falls and injury must be considered by all providers and noted on the care plan or clinical pathway. Finally, although nurses independently establish an individualized nursing database about the patient’s neurological function, collaborative practice and relationships suggest a sharing of information so that each care provider understands the database on which other providers base their care. The comprehensive neurological examination recorded on admission provides a baseline for documenting a patient’s problems and needs.
THE NEUROLOGICAL EXAMINATION
Circumstances of the Examination
The circumstances surrounding the neurological examination can vary greatly. A patient may be seen in the physician’s office, an ambulatory care center, an emergency department, or an acute care setting. The acuteness and urgency of the clinical presentation influences the initial completeness of the examination. The patient’s overall condition and level of consciousness (LOC) are key factors that influence collection of elements of the neurological examination. Many parts of the neurological examination require cooperation and the ability to follow directions. If a person has periods of confusion but can be reoriented, most aspects of the neurological examination can be completed so long as the examiner takes time to reorient and redirect the patient. However, in the case of a comatose patient, data collection is limited to responses to painful stimuli, reflexes, and a few special techniques for assessment. Other parts of the neurological examination are deferred until the patient’s condition improves.
Types of Examinations
The major components of a neurological examination are listed in Box 7-1. Neurological examinations may be classified as a screening or an extended examination. A screening neurological examination refers to a comprehensive neurological examination for persons who come for a general neurological assessment because of signs and symptoms that may be of neurological origin. A screening examination may suggest the need for further neurological investigation and an extended neurological examination and diagnostics. An extended neurological examination is an extension of the screening examination whereby the examiner follows leads from abnormal findings and expands the investigation with additional special tests to determine the presence or absence of dysfunction. A problem-focused examination is a subset of an extended examination. It is confined to a particular neurological system or region that is related to specific complaints or signs and symptoms. This chapter focuses on an initial comprehensive neurological screening examination (Box 7-2). It also includes components of the extended examination that further explores specific areas of the nervous system that require more refined techniques for evaluation.
BOX 7-1 MAJOR COMPONENTS OF THE NEUROLOGICAL EXAMINATION
Level of consciousness
Mental status examination
Cranial nerves
Motor system
Sensory system
Cerebellar system
Reflexes
Other special tests
Role of the Nurse During the Examination
The nurse may or may not be present during the neurological examination. If present, the role of the bedside nurse is to be supportive by providing brief explanations, emotional support, physical support, and assistance, as needed, with the conduct of the examination. Sometimes, the examiner may prefer to examine the patient alone, particularly if the patient is easily distracted by the presence of another person in the room. In addition, some patients tend to reveal more information to the examiner when the exchange is one-to-one.
Equipment
The usual equipment necessary to conduct a neurological examination include the following.
BOX 7-2 COMPONENTS OF THE COMPREHENSIVE NEUROLOGICAL SCREENING EXAMINATION
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Note: Abnormal findings or specific symptoms may require an extended evaluation. |
Ophthalmoscope
Reflex hammer
Tuning fork (128 Hz for vibration on bony prominences and 512 Hz for hearing)
Stethoscope
Tongue blade
Pointed instrument: which will not puncture the skin; for instance, the picky end of a broken wooden applicator is often used to apply noxious stimuli
Wisp of cotton or fluffed cotton swab to test corneal reflex and light touch sensation
Flashlight
Tape measure
Snellen or Rosenbaum eye chart
Approach
A comprehensive neurological examination is always preceded by a complete medical history and a general physical examination. The medical history will include the chief complaint, present illness, past medical history, family and social history, and review of systems. Typically, abnormal neurological findings noted in the history prompt the physician or advanced practice nurse to conduct a comprehensive neurological examination or to refer the patient to a neurologist for a comprehensive evaluation. The person conducting the comprehensive neurological examination will want to review the findings of the history and physical examination.
Generalized neurological signs and symptoms may accompany primary disease in another body system, and may even be the first evidence of such disease. In addition, neurological symptoms of either organic or psychogenic origin may include symptoms referable to other systems as a result of central or autonomic nervous system effects on visceral function. Therefore, all signs and symptoms must be adequately investigated within the context of all body systems before a neurological diagnosis is made.
Chief Complaint and History of Present Illness
After reviewing the patient’s medical record or referral information, the chief complaint and history of the present illness are collected. It is advisable to start at the beginning in collecting the complete medical history even though this has already been documented by another practitioner. An explanation to the patient will help gain cooperation. For example, one can say, “I know that you have answered some of these questions before. However, I would like to start from the beginning and collect this information without being influenced by what is in your chart so I can make an unbiased assessment of you.” Often an examiner with neurological expertise will delve into areas not included in a general physical examination. This information may be critical in making a timely and accurate diagnosis. The examiner may wish to speak with a reliable family member or significant other to collect additional information about the past medical history and chronological development of the neurological problem if the patient’s cognitive function is altered.
A complete accounting of the present illness, including onset, duration, and sequence of symptoms, must be established. Consider the defining characteristics of signs and symptoms, associated symptoms, and relieving/aggravating factors for each symptom.
Every patient with neurological complaints should be directly questioned about each of the following symptoms.1
Loss/change in intellectual abilities, onset of memory problems, difficulty with concentration, personality change, depression, or loss of drive
New onset or change in headache patterns
Seizures and loss of consciousness
Dizziness or vertigo
Loss or blurring of vision (one eye or both) or diplopia
Loss of hearing or tinnitus
Incoordination or gait difficulty
Weakness, involuntary movements
Paresthesias, sensory loss, or pain
Speech difficulties
Dysphagia
Bladder, bowel, or sexual dysfunction
Sleep difficulties (insomnia or increased sleep)
Past Medical History
A chronological past medical history is collected, including surgical procedures. Ask the patient about a history of hypertension, heart disease, stroke, diabetes mellitus, renal disease, liver disease/hepatitis, neuromuscular disease, head trauma, alcohol or drug abuse, and exposure to toxins, which may suggest risk factors. A detailed history of all prescribed and over-the-counter medications is imperative because of the high incidence of drug interactions and side effects.
Family and Social History
A family history should be collected, including drawing of a family tree for three generations. This information is helpful to suggest risk of heredetary diseases seen in families. The social history includes use of recreational drugs, alcohol consumption, and cigarette smoking. A history of high-risk sexual behavior should be elicited in light of the many neurological complications associated with acquired immune deficiency syndrome (AIDS) and hepatitis B and C.
Reviews of Systems
The review of the major body systems to determine the presence or absence of symptoms is conducted to collect information on all symptoms experienced by the patient that may be related to the current health problem.
CONDUCTING THE NEUROLOGICAL EXAMINATION
The neurological examination is conducted in a systematic, hierarchical, stepwise approach that proceeds from the highest level of function (cerebral cortex) to the lowest (reflexes) and from the general functions to specific functions. It encompasses a review of LOC, mental status/cognitive function, cranial nerves (CNs), motor system, sensory system, cerebellar system, reflexes, and special standardized scales of neurological function such as the mini-mental status examination. By approaching the neurological examination with a conceptual framework in mind, the likelihood of forgetting a part is diminished. The examiner may decide to defer certain parts of the examination. Deciding which parts can be deferred without loss of key data is difficult. The judgment and experience of the
examiner will guide these decisions. The examiner must be competent in the appropriate techniques for testing function, know when further investigation is warranted, and be familiar with the expected range of normal, age-based responses. More information about specific findings in the neurological examination is included in Chapter 8. This chapter includes the neurological examinations for both the conscious, cooperative patient and the comatose patient.
examiner will guide these decisions. The examiner must be competent in the appropriate techniques for testing function, know when further investigation is warranted, and be familiar with the expected range of normal, age-based responses. More information about specific findings in the neurological examination is included in Chapter 8. This chapter includes the neurological examinations for both the conscious, cooperative patient and the comatose patient.
The examination begins with an explanation about the examination to gain patient cooperation. The patient profile information is collected on age, gender, race, marital status, and occupation. Establish the patient’s hand dominance (i.e., left- or righthandedness). Handedness and cerebral dominance for language are closely aligned. Asking the patient if he or she is left-handed or right-handed to establish hand dominance is not sufficient and will lead to incorrect assessment because some left-handed people have been taught to write with their right hand. The following questions: “What hand do you use for throwing a ball?” or “What eye do you use to focus a camera?” can be helpful in determining side dominancy.
LEVEL OF CONSCIOUSNESS
A complete discussion of the various components of the LOC is found in Chapter 8. See discussion in the mental status examination (MSE) section.
MENTAL STATUS EXAMINATION
Many parts of the MSE are integrated into the history-taking portion of the interview. This provides a natural context for collecting information without creating an artificial test environment that could make the patient uncomfortable or anxious. The basic mental processes are the foundation to proceed to complex functions. Higher-level cognitive functions such as memory and abstraction cannot be reliably tested if basic mental functions such as attentiveness or arousal are absent. In appraising mental status, the examiner must determine whether there is any dysfunction present, whether the dysfunction is global or focal, and if global, whether it is an acute confusional state or dementia.
The MSE focuses on three general and often overlapping areas: (1) general impression of awareness and mental function, (2) reception and interpretation of sensory stimuli (general cognitive function), and (3) higher-level cognitive function (Box 7-3). An extended MSE is warranted if abnormalities are found in the screening examination. Referral for neuropsychological testing may be necessary for selected patients.
Clinical Pearl: Higher-level cognitive functions such as memory and abstraction cannot be reliably tested if basic mental functions such as attentiveness or arousal are absent.
General Impression of Patient Awareness and Mental Function
Beginning with the interview and history collection, the following areas are evaluated: level of alertness and awareness; general appearance and behavior; mood and emotional state; and thinking processes along with content of thought.
BOX 7-3 COMPREHENSIVE MENTAL STATUS EXAMINATION
General impression of awareness and mental function
Level of alertness
General appearance and behavior
Mood and emotional state
General thinking processes
Content of thought
Reception and interpretation of sensory stimuli (general cognitive function)
Orientation
Personal identification
Attention
Comprehension
Higher-level cognitive functions
Memory (immediate, short-term, long-term)
Calculations
General fund of information
Abstract thinking, reasoning, and judgment
Language and speech
Constructional ability
Motor integrative function
Level of Alertness
What the examiner must determine before conducting the neurological examination is whether the patient is awake/arousable or comatose. If the patient is comatose, proceed to the neurological examination for the comatose patient found later in this chapter. If the patient is awake or arousable, is attention sufficiently intact so he or she can cooperate and follow instructions to elicit maximum functional ability? If the answer is “yes,” proceed with the complete neurological examination. If the answer is “no,” limit the neurological examination to what can be collected within the limitations of the LOC and defer other components until the LOC is sufficient to complete the neurological examination. Delirium and dementia can affect the MSE. If dementia is suspected, the mini-mental status examination is a good screening tool.
Appearance and General Behavior
In an ambulatory setting, a patient’s attire should be appropriate for the setting and his or her age. A neat and clean appearance reflects good grooming and good personal hygiene. An unkempt appearance, conversely, suggests depression or chronic organic brain disease. Posture and movement convey clues about mental state or possible disease process. A slumped posture coupled with slow movements suggests depression or possibly Parkinson’s disease, whereas pacing suggests anxiety. Facial expression is assessed for appropriateness and variations in expression in relation to topics under discussion. In addition, observe for changes in the characteristics of the skin, features, or hair that are suggestive of other conditions such as hypothyroidism, Cushing’s syndrome, or vitamin B12 deficiency. Finally, affect and manner provide a composite of the openness, approachability, and responsiveness of the patient to the environment and other people.
Mood and Emotional State
Ask the patient about perception of his or her mood. Questions that are helpful include “How are your spirits?” “What makes you
angry?” and “What makes you sad?” Reactions to the topic being discussed and to the people around should be noted. Abnormal responses might include hostility, evasiveness, anger, tearfulness, or depression. If depression is suspected, a standardized depression screening scale can be administered for further evaluation. Of special concern is any suggestion related to suicide, which must be taken seriously. A direct inquiry can be made. One can ask “Have you ever thought about killing yourself?” or “Do you ever feel that life is not worth living?” Special observation, supervision, and further evaluation are warranted if suicidal tendencies are suspected. In addition, reports of family or friends can be very helpful in evaluating changes in mood. Identification of patients at risk for suicide is one of the national patient safety goals: “Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.” (web: www.jointcommission.org). The Beck Scale for Suicide Ideation or SAD PERSONS scale for assessing suicide risks are valid suicide risk assessment tools that can be used to prevent suicide and promote safety.
angry?” and “What makes you sad?” Reactions to the topic being discussed and to the people around should be noted. Abnormal responses might include hostility, evasiveness, anger, tearfulness, or depression. If depression is suspected, a standardized depression screening scale can be administered for further evaluation. Of special concern is any suggestion related to suicide, which must be taken seriously. A direct inquiry can be made. One can ask “Have you ever thought about killing yourself?” or “Do you ever feel that life is not worth living?” Special observation, supervision, and further evaluation are warranted if suicidal tendencies are suspected. In addition, reports of family or friends can be very helpful in evaluating changes in mood. Identification of patients at risk for suicide is one of the national patient safety goals: “Conduct a risk assessment that identifies specific patient characteristics and environmental features that may increase or decrease the risk for suicide.” (web: www.jointcommission.org). The Beck Scale for Suicide Ideation or SAD PERSONS scale for assessing suicide risks are valid suicide risk assessment tools that can be used to prevent suicide and promote safety.
Thinking Processes and Content of Thought
The overall characteristics of the thinking processes are evaluated both in response to questions and spontaneous conversation. Thought processes refer to the subjective responses to life experiences and how they are verbally expressed. Indicators of intact thought processes are clarity, cohesiveness, relevance, and logical progression and organization of thoughts. Table 7-1 lists disorders of thought processes. Thought content refers to themes in expression of ideas. By active listening, reflecting, and exploring the answers provided, the examiner can evaluate the presence of abnormal themes such as compulsive behaviors (i.e., compulsions, obsessions, phobias), anxieties, feelings of unreality, depersonalization, persecution or control by others, delusions, and perceptual deficits (i.e., illusions and hallucinations).
TABLE 7-1 VARIATIONS/ABNORMALITIES IN THOUGHT PROCESSES | ||||||||||||||||||||||||||||||||||||
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Perception is a person’s subjective interpretation of real or perceived stimuli. Illusions and hallucinations are common abnormal perceptual findings. Illusions are the misinterpretation of real external stimuli. Hallucinations are subjective sensory perceptions in the absence of real external stimuli and may be categorized as auditory, visual, olfactory, gustatory, tactile, or somatic. Evidence of illusions or hallucinations may indicate depression, mental illness, or organic disease necessitating further evaluation.
Throughout the interview note the characteristics of speech. Speech is the motor activity for the expression of language, and is controlled by the lower CNs and their supranuclear connections. Listen to the fluency (i.e., rate, flow, melody of speech, content, use of words) of speech. Note the quality, volume, tone, articulation, inflections, and spontaneity of the speech. Slow monotone speech may be suggestive of depression, whereas rapid and loud speech is common in manic states. Problems with articulation (i.e., clarity and distinctness of the spoken word) are associated with dysarthria. Dysarthria is a disorder of articulation in which basic language (i.e., grammar, comprehension, and word choice) is intact. Nerve, brain, or muscle disorders make it difficult to use or control the muscles of the mouth, tongue, larynx, or vocal cords thus resulting in distorted speech. The sounds produced are distorted and often nasal. An interruption of speech inflections and rhythm (i.e., speech melody) is called dysprosody. The resulting speech is monotone and halting.
Reception and Interpretation of Sensory Stimuli
The reception and interpretation of sensory stimuli, including awareness and responsiveness of self, the environment, and the impressions made by the senses, are referred to as sensorium. The areas included in the evaluation are orientation, personal identification, attention, concentration, and comprehension. These functions may be clouded by focal or diffuse cerebral conditions, such as a brain tumor, vascular and degenerative disease, or encephalitis.
Orientation
Orientation is the awareness of time, place, and person and is evaluated by direct questioning.
Time: the time of day, day of the week, month, season, date, and year, as well as any upcoming holiday or one in the immediate past may be asked. For some patients, however, a more direct approach, using specific questions (e.g., “What day is it today?”) is indicated.
Place: ask the patient to give the present location, such as “I am at Mercy Clinic in Detroit, Michigan.”
Person: ability of the patient to give his or her own name.
Orientation is usually lost in the following order, first to time, next to place, and finally to person.
Personal Identification
In the context of evaluation, ask the patient’s name, address, and background information such as date and place of birth, history of the illness, and specific dates of significant life events; this will provide insight into awareness of time, place, and person. This information should be corroborated using the medical record or verification by a family member.
Attention and Concentration
Attention is the ability to focus on a particular sensory stimulus while excluding others; concentration is sustained attention. In an acute confusional state, attention and concentration are severely impaired. By contrast, both are intact with focal lesions. Attention and concentration are tested in a number of ways, including number series, serial 7s, and spelling backward.
Number Series. Read a series of digits to the patient and then ask him or her to repeat the numbers. The series should start with a short list, with each digit being enunciated clearly and paced at 1-second intervals. Number series can begin with two digits, then progress to a maximum of six digits (e.g., 7, 2; 9, 5, 2). Avoid consecutive numbers or digits that form easily recognizable combinations, such as the date 1776. If the patient makes an error in repeating the digits, provide a second chance with another series of digits of similar length. Stop after two consecutive failures in a series of any length. In the second part of this test (beginning with the shortest list of digits), the patient is asked to repeat a series in reverse order. Normally, a person should be able to repeat correctly five to seven digits forward and four in reverse order.
Serial 7s. Another common method is to ask the patient to start with 100 and subtract 7s. Normally, one should be able to complete this task with few errors in 90 seconds. In practice, if a patient can accurately complete five subtractions, this is usually sufficient. Patients unable to do serial 7s should be instructed to complete serial 3s in a similar manner.
Spelling Backward. Say a five-letter word and ask the patient to spell it backward. The word commonly used is W-O-R-L-D.
Comprehension
Evidence of the level of comprehension and perception can be noted throughout the examination. Comprehension is the ability to grasp and understand the meaning of visual, auditory, and other stimuli within the context of the total situation accurately. Comprehension, perception, attention, reasoning, and making decisions are complex processes; they contribute to other mental functions such as memory, judgment, general knowledge, and intelligence.
Higher-Level Cognitive Functions
Higher-level cognitive functions include several higher cognitive and integrative functions. In evaluating responses, consider what someone of comparable cultural and educational background would be expected to know. Testing of these higher-level intellectual abilities includes the following.
Memory (immediate, short-term, long-term)
Calculations
General fund of information
Abstract thinking, reasoning, and judgment
Language and speech
Constructional ability
Motor integrative function
Memory
Memory is the ability to register, store, and retrieve information. Registration, the ability to receive information through the various senses, is closely related to attention. Without the ability to attend, information will not register. Storage is the process whereby selected new information is learned; it is mediated by the limbic structures, including the hippocampi, the mamillary bodies, and the dorsal medial nuclei of the thalami. After the sensory input has been received and registered, that information is held temporarily in the short-term memory or working memory. Next, the information is stored in a more permanent form (long-term memory). Stored information is reinforced by repetition or by association with other information already in storage. Retrieval, the final step, is the ability to access previously learned information.
Memory can be subdivided into three general categories and includes immediate memory, short-term memory, and long-term memory. Immediate memory, also called primary memory, is the retrieval of information within seconds or minutes after presentation as in repeating a series of digits. Short-term memory, also referred to as recent memory, is the ability to remember current, day-to-day events such as the date, the name of the health provider, what was eaten for breakfast, or a recent news event. Long-term memory, also referred to as remote memory, refers to the recollection of personal and historic facts or events. The clinical significance between short-term memory and long-term memory is that short-term memory requires the ongoing ability to learn new information. See Table 7-2 for a comparison of memory types.
In testing immediate memory, give the patient three unrelated words to remember (e.g., lilies, courage, and screwdriver). Ask the patient to repeat each word after you. Then, ask the patient to tell you those three words; this tests immediate memory. Instruct the patient to remember those three words because you will be coming back to them in a few minutes. Go on with the examination. In 3 to 5 minutes, ask the patient to tell you what those three words were. Normally, the patient should be able to remember the three words; this is a test of short-term memory. In testing long-term memory, the following are suggestions for typical personal and historical information.
Date/place of birth:
When were you born?
Where were you born?
School information:
Where did you go to school?
TABLE 7-2 CLASSIFICATION OF MEMORY
TYPES OF MEMORY
PRIMARY PURPOSE
ACCESSIBILITY/CAPACITY
DURATION
ANATOMIC SITE
TESTING METHOD
CLINICAL PRESENTATION
Immediate (primary)
Register new information
Rapid accessibility
Limited capacity
Seconds to minutes
Reticular activating system (RAS)
Immediately repeat a series of numbers
Lack of any memory
Recent (short-term)
Retention and recall of information that has been previously registered
Slow accessibility
Much larger capacity
Minutes to years
Limbic system
Repeat names of three objects after being distracted for 3-5 min
Inability to recall information previously registered
Remote (long-term)
Permanently retain information
Slower accessibility
Unlimited capacity
Years
Association cortex
Correctly recall important personal events of the past
Cannot recall highly significant past material
Adapted from Tasman, A., & First, M. B. (2004). DSM-IV-TR mental disorders: Diagnosis, etiology, and treatment (pp. 276-277). Hoboken, NJ: Wiley.
When did you attend school?
Where is your school located?
Vocational history:
What do you do for work?
Where do you work?
How long have you worked there?
Family history:
What are your spouse’s and children’s names?
How old are they?
What was your mother’s maiden name?
Memory can be affected by a number of focal and diffuse organic conditions as well as emotional states. Amnesia is defined as a defect in memory function and may be an isolated deficit or one component of global cognitive dysfunction. Amnesia is classified into specific categories as follows.
Retrograde amnesia: loss of memory for events that occurred before a brain insult
Antegrade or posttraumatic amnesia: loss of memory for events after a brain insult
Psychogenic amnesia: loss of memory for an emotionally charged event
Calculations
Serial 7s give some indication of subtraction ability. In addition, simple calculation problems should be asked.
How much is a quarter, a dime, and a nickel?
How much is 3 × 9?
How much is 11 + 7?
General Fund of Information
To evaluate the patient’s general knowledge, consider the patient’s cultural and educational background. Ask about current events or general information that you would expect an average adult to know who lives in the area. Examples of questions are the following.
Who is the president of the United States?
Name the last five presidents from the current president backward.
What is the capital of England?
Abstract Thinking, Reasoning, and Judgment
An appraisal of abstract thinking, reasoning, and judgment may begin while taking the history, but a closer evaluation is warranted.
Abstract Thinking. Abstract thinking is the ability to appreciate subtle relationships and meaning in events and between objects. This can be evaluated through the use of proverbs and similarities. For example, ask the patient what is meant by the following proverbs.
All that glitters is not gold.
Rome wasn’t built in a day.
People who live in glass houses should not throw stones.
Rolling stones gather no moss.
A literal, concrete interpretation may indicate organic brain disease, mental illness, mental retardation, or simply limited education.
Similarities. In evaluating ability to recognize similarities, ask the patient to explain how two given objects are alike, such as the following.
A rose and a carnation
A piano and a violin
Silk and linen
Reasoning. The ability to use intellectual faculties to discover, formulate, or draw a conclusion is called reasoning. This can be evaluated by asking the patient to define or differentiate between combinations such as a mistake and a lie, or sadness and hopelessness.
Judgment. The process of forming an opinion or evaluation about something is called judgment. It often includes a component of insight, the act of seeing the inner nature of things or of seeing intuitively. The examiner can evaluate a patient’s judgment and insight by asking questions such as “What seems to be the problem?” or “Why are you here today?” A person might say that he or she is here to be evaluated because of certain signs and symptoms. Conversely, a patient might say that there is nothing wrong, but his or her spouse insisted on the visit. The latter suggests a lack of insight due to denial, being unaware of the relationship of symptoms to illness, or parietal lobe syndrome. To appraise judgment, ask questions such as “How are you going to manage at home after hospitalization?” or “What activity limitations do you need to follow?” The examiner can determine how accurate and reasonable the judgments are based on the patient’s age and education.
TABLE 7-3 EVALUATION OF LANGUAGE AND SPEECH | ||||||||||||||
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Language and Speech
Language is the basic tool for human communication and often the medium for demonstrating most cognitive functions. Normally, a person can understand the spoken and written word and also express thoughts verbally and in writing. Disturbances of language and speech are divided into three areas.
Disorders of central language processing result in aphasia.
Disorders of motor programming of language symbols result in apraxia of speech.
Disorders of the motor mechanism of speech result in dysarthria.
Language and speech are evaluated throughout the patient-provider interaction. If there are deficits in the language system, it will be difficult, if not impossible, to test cognitive skills such as memory, proverb interpretation, or oral calculations. Word comprehension, repetition, naming, fluency, reading, and writing are all essential elements of the language system and all are tested (Table 7-3).
TABLE 7-4 CLASSIFICATION OF APHASIAS WITH ANATOMIC CORRELATIONS | |||||||||||||||||||||||||||
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Aphasia is a language disorder due to a dominant hemisphere lesion that produces a defect in the expression or comprehension of any component of language. Aphasia used to be subdivided into nonfluent (expressive) aphasia and fluent (receptive) aphasia, but is now classified on a functional basis. The main types of aphasias include Broca’s aphasia, Wernicke’s aphasia, global aphasia, conduction aphasia, anomic aphasia, transcortical aphasia, and verbal apraxias. See Tables 7-4 and 7-5 for summarization of aphasias and Figure 7-1 for anatomic locations. Most patients have varying
degrees of expressive and receptive language deficits, emphasizing the interrelatedness of cortical function.
degrees of expressive and receptive language deficits, emphasizing the interrelatedness of cortical function.
TABLE 7-5 CLASSIFICATION OF APHASIA AND IMPACT ON LANGUAGE FUNCTION | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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 Figure 7-1 ▪ Anatomic pathways involved in (A) reading a sentence and repeating it out loud and (B) hearing a question and answering it. Note that Wernicke’s area is connected to Broca’s area by a bundle of nerve fibers called the arcuate fasciculus. |
Repetition is impaired in Broca’s, Wernicke’s, conduction, and global aphasias. However, when repetition is preserved in a patient with Broca’s aphasia, it indicates transcortical motor aphasia and the lesion is anterior to Broca’s area. Preservation of repetition in Wernicke’s aphasia is termed transcortical sensory aphasia and the lesion is posterior to Wernicke’s area. Aphasia must be distinguished from other speech production disorders, including speech apraxia, mutism, and dysarthria. Motor speech (verbal) apraxia results from a focused lesion in Broca’s areas (areas 44 and 45). It is characterized by a partial or complete inability to form the articulatory movements of the lips, tongue, and lower jaw to produce individual sounds that constitute words. The patient knows what he or she wants to say but is unable to execute the motor aspects of speech.2 Mutism is a lack of speech production caused by lesions of the prefrontal areas and cingulate gyrus. Dysarthria is the inability to articulate spoken words; it involves the motor component of speech but not a deficit with language. Clear speech involves coordinated and modulated activity of muscles supplied by CNs V, VII, IX, X, and XII as well as the respiratory muscles. Dysarthria occurs with disorders of the direct and indirect motor pathways, the motor control circuits, and the lower motor neuron system. This is discussed in the section on assessment of the CNs.
Constructional Ability
Constructional ability, the ability to reproduce figures or draw a figure on command, can be assessed easily if the patient has motor function in his or her writing hand. This ability can be tested in a number of ways. One option is to draw two five-sided figures that overlap to form a four-sided figure, and then ask the patient to copy it. Another option is to ask the patient to draw a clock with all the numbers and to set the clock at a given time. A variation for this drawing is a daisy with petals equally arranged around the center. Abnormalities of visuospatial function and construct abilities are seen in right, but also in left or bilateral, parietal-occipital lesions. Patients with a nondominant parietal lesion may have a hemispatial neglect syndrome resulting in nothing being drawn on one half of the clock or flower (Fig. 7-2 shows sample drawings).
Motor Integrative Function: Apraxia
Performing a skilled act on demand requires integrated functions of several areas of the cerebral cortex. Three steps are necessary to execute a purposeful, skilled act successfully, as detailed in Table 7-6. To perform a skilled motor act, a person must understand what the act entails, remember the steps long enough to complete the act, and possess normal motor strength. If a patient is unable to perform a learned skilled motor act (in response to a verbal command) in the absence of paralysis, comprehension deficit, uncooperative behavior, or other obvious reasons, the term apraxia is applied. Ask the patient to pantomime activities for you such as brushing the teeth, combing the hair, blowing out a match, and expressing surprise.
TABLE 7-6 PURPOSEFUL MOTOR ACTS AND APRAXIA | ||||||||||||||||
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 Figure 7-2 ▪ Examples of impaired performance on a test for copying given to a patient with unilateral neglect. |
Clinical Pearl: A decrease in the level of alertness occurs only if there is dysfunction of both cerebral hemispheres or the brainstem. There is no one-to-one correlation between a MSE task and a single cognitive function; mental tasks are complex and require a number of cerebral areas and cognitive functions. None of the focal deficits in the MSE has any localizing significance.
CRANIAL NERVE EXAMINATION
The next part of the neurological examination focuses on the central nervous system. There are 12 pairs of CNs. Each CN has a left and a right nerve; each side must therefore be evaluated separately. There may be dysfunction on one side only or on both sides. Findings from each side are compared for symmetry. This chapter is organized to include details of testing, discussion of findings, and
abnormal findings. See Chapter 5 for a review of the anatomy and physiology of the CNs.
abnormal findings. See Chapter 5 for a review of the anatomy and physiology of the CNs.
Olfactory Nerve (Sensory) (CN I)
Testing of the olfactory nerve is often deferred unless the patient reports deficits or there is reason to believe that this function is compromised. If indicated, the sense of smell is tested by obstructing one nostril while testing the other. With the patient’s eyes closed, a piece of cotton that has been saturated with a common, odoriferous, nonirritating substance is placed under the unobstructed nostril. Cinnamon, cloves, coffee, or peppermint are possible odors that patients should be able to identify if CN I is intact. Items such as toothpaste from the patient’s bedside may be used to conduct the test.
Abnormalities
Anosmia is an inability to smell. It is an early sign in the diagnosis and localization of frontal lobe tumors. There are several causes of anosmia, some of which are attributable to neuropathologic conditions such as meningiomas of the sphenoid ridge and olfactory groove, gliomas of the frontal lobe, infectious processes involving the meninges at the base of the frontal lobe, toxic substances including lead and calcium, and parasellar lesions with pressure on the olfactory bulbs or tracts. Common non-neurological causes of anosmia include the common cold, sinusitis, or inflammation of the nasal cavity. The typical syndrome with sphenoidal ridge meningioma is one of unilateral optic atrophy or papilledema, exophthalmos, and ipsilateral anosmia. A meningioma of the olfactory groove or cribriform plate area includes unilateral anosmia progressing to bilateral anosmia, often accompanied by unilateral ipsilateral optic atrophy, and contralateral papilledema.1
Optic Nerve (Sensory) (CN II)
The optic nerve is the only CN that can be examined directly. Testing encompasses an evaluation of visual acuity and visual fields and an ophthalmoscopic examination. Each eye is evaluated individually while the other eye is covered.
Visual Acuity
Visual acuity can be evaluated informally by asking the patient to read from printed material, such as a newspaper. A standard Snellen chart is available in office or clinic settings and other settings such as the emergency department for formal testing. Each eye is checked individually. From a distance of 20 ft (6.1 m); the patient is asked to read the line on the chart with the smallest letters that he or she is able to read. The number beside each line of letters signifies the number of feet at which letters can be read by a person with normal vision. This becomes the denominator in recording vision. Normal vision is 20/20. When vision is defective, the patient may only be able to see the larger letters at 20 ft (6.1 m). For example, persons with 20/40 vision are able to see at 20 ft (6.1 m) what those with normal vision can see at 40 ft (12.2 m).
An adaptation of the Snellen chart, the Rosenbaum Pocket Vision Screener, is designed for quick bedside use. The chart is held at a distance of 14 in (0.36 m) from the patient. Normal vision in this instance is 14/14. The ratio is calculated in the same manner as for the Snellen test.
Visual Fields
A visual field is the area of vision normally seen with one eye. Each visual field extends 60 degrees on the nasal side, 100 degrees on the temporal side, and 135 degrees vertically (60 degrees superiorly and 75 degrees). Figure 7-3 displays normal visual fields. The confrontation test provides a rough estimate of the scope of each visual field. This is a test in which the examiner “confronts” the patient by sitting 2 ft (0.6 m) in front of him or her at eye level. The patient is asked to cover one eye lightly and look at the examiner’s eye directly opposite (i.e., the patient’s left eye will be looking at the examiner’s right eye). The examiner then closes one eye, the one the visual field of which is not being currently used, thus isolating the visual field in the other eye and superimposing it on that of the patient’s visual field. A pencil or a moving finger is then introduced from the periphery into the patient’s field of vision; each quadrant (upper and lower) is checked individually. The patient is asked to indicate when the object is first seen. The examiner uses his or her own visual field as the norm for comparison to the patient’s visual field.
The confrontation test is designed to reveal only gross defects of the visual fields. If any defects are found, the visual fields should be plotted by an ophthalmologist using the standard and more sensitive perimetric test or a tangent screen. Visual field testing can reveal field cuts related to characteristic deficits along the visual pathway (i.e., optic nerve, optic tract, lateral geniculate body, geniculocalcarine tract, or occipital lobe). Chart 7-1 shows specific field cuts; Figure 7-4 shows field cuts in a person with right homonymous hemianopia.
With bilateral occipital or occipitoparietal infarctions, there may be cortical blindness resulting in complete loss of vision often with denial or unawareness of the deficit. Cortical blindness is referred to as Anton’s syndrome. Because the pupils still react to light, cortical blindness may be difficult to differentiate from hysterical blindness.
Ophthalmoscopic Examination
The ophthalmoscopic examination is conducted with an ophthalmoscope, which contains a special lens that is used to visualize the retina by shining a beam of white light directly into the eye. The room is darkened and the examiner sits directly opposite the subject. To examine the patient’s right eye, the examiner holds the ophthalmoscope in the right hand and looks through the instrument with the right eye while the patient focuses on an object straight ahead (Fig. 7-5). Shine the beam of light on the pupil and look for the red reflex—an orange glow reflected from the retina. Move closer toward the pupil, staying focused on the red reflex. The termination of the optic nerve, visible as a prominent, tube-like structure at the back of the eyeball and slightly to the nasal side of center, is called the optic disc. Bring the optic disc (fundus) into focus by adjusting the ophthalmoscope lens (Fig. 7-6). The normal disc is round or slightly oval with sharply defined margins. The outer portion of the disc is elevated slightly above the center, or physiologic cup. Another area of the retina is the macula lutea, which has the highest density of visual receptors. The center of the macula, called the fovea, represents the point of greatest visual acuity.
Four main pairs of blood vessels exit and enter the optic disc; they are followed peripherally in all directions to compare the diameters of the arteries and veins and to determine whether the veins are tortuous. Normally, the diameter of the veins is about 30% greater than the diameter of the arteries in a ratio varying from 2:3 to 4:5. Retinal venous pulsation is seen in 80% of normal people. The presence of retinal venous pulsation indicates normal intracranial pressure; the absence may be normal or may reflect raised intracranial
pressure. As the retina is examined, any abnormalities, such as hemorrhage, swelling, and exudate, should be noted. Table 7-7 summarizes common ophthalmological findings.
pressure. As the retina is examined, any abnormalities, such as hemorrhage, swelling, and exudate, should be noted. Table 7-7 summarizes common ophthalmological findings.
 Figure 7-3 ▪ Normal visual fields. |
 Figure 7-4 ▪ Right homonymous hemianopia in a patient with a neoplasm of the left occipital lobe. |
CHART 7-1 Visual Field Defects Produced by Selected Lesions in the Visual Pathways | |||||||||||||
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 Figure 7-5 ▪ Technique for the proper use of the ophthalmoscope. Turn on the ophthalmoscope light and adjust the output to the small round beam of white light. Use your index finger to adjust the lens for proper focus; begin by adjusting the lens to zero diopters. Red lens numbers indicate minus diopters (turn the lens control counterclockwise) and are used with a myopic (nearsighted) patient. Black lens numbers indicate plus diopters (turn the lens control clockwise) and are used for a hyperopic (farsighted) patient or for one who has undergone surgical lens removal. Instruct the patient to look straight ahead. Hold the ophthalmoscope with your right hand and use your right eye to look into the patient’s right eye. Hold the thumb of the opposite hand on the patient’s eyebrow above the eye that you are examining.
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